Dr. Smith's ECG Blog

JUNE 11, 2024

Now it is a full blown STEMI of 3 myocardial territories: inferior, posterior, and lateral But at least it does not call it "Normal." Successful drug-eluting stent placement opening up 95% mid RCA stenosis to 0% residual Nonobstructive left system disease. Formal echocardiogram: Systolic function is at the lower limits of normal.

Chest Pain 113

Chest Pain STEMI Blog Exercise 113

Dr. Smith's ECG Blog

MARCH 2, 2009

reports MI in 2001 with a stent placed in the "marginal" artery. A stat echocardiogram would have helped to make this diagnosis and facilitate timely reperfusion. First, this patient had a known stent in the "marginal" artery and thought he was having a heart attack. Pain is similar, but associated with less SOB.

Heart Attack 52

Heart Attack Heart attacks STEMI Echocardiogram 52

Dr. Smith's ECG Blog

NOVEMBER 22, 2023

See this post: What do you think the echocardiogram shows in this case? 20% of cases that everyone would call a STEMI have a competely open artery by the time of angiogram 60-90 minutes later. Important point: when there is diffuse subendocardial ischemia but no OMI, a wall motion abnormality will not necessarily be present.

Chest Pain 119

Chest Pain Ischemia Echocardiogram Myocardial Infarction 119

Dr. Smith's ECG Blog

DECEMBER 29, 2015

would require the ST/S ratio to be 25% for diagnosis of STEMI in LVH. The physician was concerned about STEMI, but also worried that she was overreacting, with the potential that LVH was producing a "STEMI-mimic." No prior echocardiogram was available for comparison. Can you diagnose an ACO (STEMI) when you also have LVH?

STEMI 40

STEMI Myocardial Infarction Chest Pain Aneurysm 40

Dr. Smith's ECG Blog

NOVEMBER 2, 2015

Formula value is now down to a very low value of 19.352 A 90% thrombotic LAD lesion was found and stented. Serial ECGs demonstrated dynamic changes diagnostic of ACS (transient STEMI) 4. Finally, Transient STEMI should be taken emergently to the cath lab. The first (and only) ED ECG is here: QTc 386.

STEMI 52

STEMI Myocardial Infarction Chest Pain Echocardiogram 52

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." Here is the angiogram after stent placement. Her contrast enhanced echocardiogram is shown below in the parasternal short axis view.

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Myocardial Infarction Chest Pain STEMI Blood Pressure 123

Dr. Smith's ECG Blog

JANUARY 1, 2013

Precordial ST depression may be subendocardial ischemia or posterior STEMI. If you thought it might be a posterior STEMI, then you might have ordered a posterior ECG [change leads V4-V6 around to the back (V7-V9)]. So there was 3-vessel disease, but with an acute posterior STEMI. There is no ST elevation. See the list below.

STEMI 52

STEMI Ischemia Chest Pain Myocardial Infarction 52

Dr. Smith's ECG Blog

OCTOBER 22, 2024

Unfortunately, the cardiologist waited until the next day to refer the patient for angiography and intervention because patient did not meet criteria for "STEMI"." Successful primary angioplasty of the mid-circumflex artery towards the main marginal branch with the implantation of a drug-eluting stent. Good angiographic result.

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Chest Pain STEMI Myocardial Infarction Angioplasty 66

Dr. Smith's ECG Blog

NOVEMBER 15, 2013

You've read in my previous posts that I have a lot of evidence that Wellens' represents spontaneously reperfused STEMI in which the STEMI went unrecorded. New ST elevation diagnostic of STEMI [equation value = 25.3 It was stented. This T-wave inversion morphology is very specific for Wellens' waves.

Chest Pain 52

Chest Pain Thrombosis Myocardial Infarction STEMI 52

Dr. Smith's ECG Blog

JULY 3, 2018

Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve Smith Case A 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain similar to his prior MI, but worse. Despite ongoing chest discomfort and an uptrending troponin, he never meets STEMI criteria.

Pericarditis 52

Pericarditis Chest Pain Stents Stent 52

Dr. Smith's ECG Blog

DECEMBER 19, 2023

Unfortunately, we do not have those images for review, but the operators described a ruptured LAD plaque and they stented this area, which ensures the stability of the plaque. His echocardiogram showed normal wall motion. The patient did well afterward without any recurrence of symptoms. Before and after of the LAD shown below.

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Plaque Angina Blog Stent 127

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

EKG initially negative but repeat shows a few T wave abnormalities… There is a chance this could be non-cardiac pain” At 1518, an echocardiogram showed normal LV size and systolic function with hypokinesis of the mid and distal anterior wall and the mid and distal septum. At 1605, another repeat troponin resulted at 5.271 ng/mL.

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Chest Pain Blog Hospital Tachycardia 120

Dr. Smith's ECG Blog

AUGUST 6, 2024

Elevated troponins prompted an echocardiogram — which revealed an apical wall motion abnormality (WMA). It definitely does not fulfill STEMI criteria, and I would argue that it would not lead to cath lab activation in most centers. Patient #1 in today's post did not get expert ECG interpretation. The ECG shows ST depression in lead V3.

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Chest Pain Ischemia Pericarditis Tachycardia 104

Dr. Smith's ECG Blog

MARCH 9, 2013

Here is the prehospital ECG, with pain:  Hyperacute anterolateral STEMI  The medics had activated the cath lab and the patient went for angiogram and had a 95% stenotic LAD with TIMI-3 flow. A stent was placed. For those who depend on echocardiogram to confirm the ECG findings of ischemia, this should be sobering.

Chest Pain 52

Chest Pain Myocardial Infarction Ischemia Angina 52

Dr. Smith's ECG Blog

OCTOBER 28, 2013

The last section is a detailed discussion of the research on aVR in both STEMI and NonSTEMI. The additional ST Elevation in V1 is not usually seen with diffuse subendocardial ischemia, and suggests that something else, like STEMI from LAD occlusion, could be present. It was stented. If you want to understand aVR, read this.]

Cardiac Arrest 52

Cardiac Arrest Ischemia Defibrillator Electrocardiogram 52

Dr. Smith's ECG Blog

MARCH 28, 2017

EMS recorded these ECGs: Time 0: In V2-V4, there is ST elevation that does not meet STEMI "criteria," of 1.5 She was having a transient STEMI, briefly. It did not progress to full STEMI with loss of the anterior wall, as in this case. It was stented. She called 911. mm at the J-point, relative to the PQ junction.

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STEMI Risk Factors Bicuspid/Mitral Ultrasound 40

Dr. Smith's ECG Blog

OCTOBER 2, 2021

He was successfully treated with one drug eluting stent. He underwent formal echocardiogram several days later, which confirmed the findings of anterior, and apical wall motion abnormalities. Practice putting the probe on the chest of someone with an obvious STEMI(+) OMI in order to look for regional wall motion abnormalities.

Chest Pain 52

Chest Pain Ultrasound STEMI Myocardial Infarction 52

Dr. Smith's ECG Blog

FEBRUARY 4, 2022

They were stented. Formal Echocardiogram: The estimated left ventricular ejection fraction is 58 %. These include about 60 occlusion MI (OMI) with clear ST segment elevation (none of which would be called “Normal” by the computer) and about 165 Non-STEMI. The peak troponin was 1863 ng/L. Why not very very high?

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Chest Pain STEMI Article Myocardial Infarction 52

Dr. Smith's ECG Blog

SEPTEMBER 30, 2019

Slow TIMI 2 initially with brisk flow status post percutaneous coronary intervention with 18mm drug-eluting stent. Unfortunately there is no echocardiogram accessible because the patient checked himself out of the hospital in order to get back to his home state before it could be completed. To our knowledge, the patient did well.

Chest Pain 52

Chest Pain Pulmonary ACE Inhibitor Pacemaker 52

Dr. Smith's ECG Blog

NOVEMBER 1, 2022

The 50-something patient with history of coronary stenting and slightly reduced LV ejection fraction. In the setting of prior stenting and reduced left ventricular ejection fraction, would pursue a heart team revascularization approach Syntax score 28.5, This alone could be due to LVH, but V4 could NOT be due to LVH.

Chest Pain 52

Chest Pain Coronary Artery Bypass Graft Pericarditis Blog 52

Dr. Smith's ECG Blog

JULY 31, 2018

It is equivalent to a transient STEMI. Not much, but studies of STEMI and NonSTEMI show that about 70% of those diagnosed with STEMI have a peak troponin I above 10 ng/mL and that about 70% of those diagnosed with NonSTEMI have a peak troponin I below 10 ng/mL. The lesion was stented. Again, cath lab was not activated.

SCAD 52

SCAD Chest Pain Myocardial Infarction Ischemia 52

Dr. Smith's ECG Blog

DECEMBER 18, 2022

Compare to the anatomy after stenting: The lower of the 2 now easily seen branches is the circumflex, now with excellent flow. Next day echocardiogram showed inferolateral hypokinesia with an EF of %45-50. This is seen just millimeters beyond the tip of the catheter. The patient recovered well. His peak troponin was over 5000 ng/L.

Myocardial Infarction 40

Myocardial Infarction Chest Pain Blog Echocardiogram 40

Dr. Smith's ECG Blog

SEPTEMBER 29, 2018

I think a good start would be a posterior EKG and a high quality contrast echocardiogram read by an expert. It was thought to be an in stent restenosis and thrombosis from a DES placed in the same region 6 months prior. His prior EF from an ECHO 6 months prior indicated 35% LVEF. What would you do in this scenario?

Chest Pain 52

Chest Pain Myocardial Infarction Cardiac Arrest Ischemia 52

Dr. Smith's ECG Blog

NOVEMBER 10, 2024

The is very small STE in III and aVF which do not meet STEMI criteria, hyperacute T waves, reciprocal TWI in aVL, and maximal STD in V2-V3 showing posterior OMI. The cath lab was activated despite lack of STEMI criteria, around 2 am in the morning. 33% of STEMI are reperfused by the time of angiography. Very frustrating.

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STEMI Chest Pain Echocardiogram Stent 81

Dr. Smith's ECG Blog

FEBRUARY 16, 2025

The emergency medicine physician documented, "His initial EKG is riddled with artifact and difficult to interpret but does not look like a STEMI." The ECG remains positive for STEMI by GE. Echocardiogram was finally performed five hours after the first diagnostic ECG. The emergency physician consulted cardiology.

STEMI 72

STEMI Pericarditis Chest Pain Echocardiogram 72

Dr. Smith's ECG Blog

FEBRUARY 2, 2025

Unfortunately, the ECG was interpreted as no significant change from prior , "no STEMI"!! Approximately 5 minutes after ROSC, this ECG was obtained (about 45 minutes after arrival): Obvious anterolateral OMI, and STEMI criteria positive for those who care or need it. He was sent back to the waiting room, where he suffered a VF arrest.

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Cardiac Arrest STEMI Blog Ischemia 86